MORGANTOWN — While the state Department of Health and Human Resources’ Bureau for Medical Resources believes its new system for calculating the Medicaid care budgets for people with intellectual and developmental disabilities will be more transparent and accurate, stakeholders aren’t convinced it will work any better.
The program is the Medicaid Title XIX Intellectual/Developmental Disability (IDD) Waiver program. It serves 4,634 people.
The West Virginia Behavioral Health Providers Association contracted national consultant Health Management Associates to analyze the new system. HMA found some pros, but more cons.
HMA acknowledges DHHR’s claim the new system is more transparent. It adds that the new process considers different factors for youth and adults, budget add-ons consider the client’s functional capabilities, and “administrative process and communication with members may improve.”
Among the cons:
Budgets are already based on 2016 figures, which in a large number of cases had been cut from 2104 levels after DHHR denied requests for funding above what the algorithm kicked out. So the figures may not be based on true need. Conversely, a client may have experienced an unusual need in 2016 and seen a budget spike that will inflate future budgets.
With annual re-basing, clients may see a “downward spiral effect” because subsequent budgets will be based on previous-year spending and not need for services.
The model puts the risk on the client to prove need above the upper level of the budget matrix, “rather than the use of an appropriate needs assessment and proper care planning by the state.”
The stop-gain 20 percent cap may be subject to federal review. The upper limit is likely to reinforce individual risk and the downward spiral, and “raise questions regarding the clinical appropriateness of the assessment methodology.”
The ICAP (Inventory for Client and Agency Planning) is not designed to be a budget tool. It’s an assessment and planning tool that doesn’t adequately account for behavioral deficits.
This money-based model raises questions about person-centered planning. It may raise barriers to placing the client in appropriate community settings.
It may encourage a use-it-or-lose-it approach to spending. Teams and clients may spend the entire budget even if they don’t need to in order to avoid next-year cuts.
Rather than go full-in on this new process, HMA suggests, it would be wiser to enact a plot program with a representative sample of care agencies to test the new model and work out the bugs.
Valley HealthCare
Valley HealthCare of Morgantown provides IDD Waivers services for this area. Both Chief Financial Officer Greg DeMasi and Ashley Malott, program manager of I/DD Waiver Service Coordination and Behavior Support Professionals have voiced concerns.
Valley has a number of clients in group home settings. DeMasi said in an a previous email exchange, “All of our clients will receive the maximum budget cut of 20 percent this year, and seven clients will hit the 20 percent maximum cap this year and receive further reductions next year.”
Group home care costs range from $114,000 to $146,000, DeMasi said. Under the new system, with all available add-ons, the maximum budget will be $104,500 for a high-need client. “The 20 percent budget reduction per client equates to a significant changes in the services that the clients can receive.” For some, day treatment will be off the table.
“In essence,” he said, “the budget reductions are going to cause a 20 percent reduction in the services a client receives; the clients will be serviced at higher [staff to client] ratios; and any external ancillary services provided outside of the home, such as day programming, will be eliminated. The clients are going to be made shut-ins in their own homes.”
Mallott cited 13 examples of how clients will face budget cuts in group homes and in their family homes. Here are a few.
A person residing in a four-person group home and budgeted for $132,437.74, with $144,556.14 of actual costs (Valley would provide the remainder uncompensated) for the current fiscal year will receive a budget of $96,455 under the new system.
An adult living at home and budgeted $60,737.58 for the current year, and spending $67,069.61, will see $56,594 under the new system.
And a minor at home budgeted $91,000.44 for the current year, and spending $53,958.22 (a Monday story spelled out how many minors in the program are assigned budgets far larger than they are allowed to use) will see a new budget of $45,444 — $8,514.22 less that what was spent this year.
“It’s going to really negatively affect other people beyond the people who live in a residential setting,” Mallott said. “We’ve already had to cut all of their services to get them down to where they are now. So now if their assigned budget is going to be even less, there’s nothing left to cut at this point.
Clients won’t receive or attend therapy or attend day programs as much as they used to or need to. “It’s just an awful situation, really.”
She continued, “For someone living with their family, the family is just going to have to take on that additional burden and hardship.”
For those in a group home, the staff-to-client ratios will suffer. “That’s just awful for the clients who need the care and attention of someone working individually with them and being able to dedicate more time with them. It’s spreading the staff a little thin having them work with so many people at once.”
Valley HealthCare President and CEO confirmed that the agency has to operate at a loss by providing uncompensated or undercompensated care when budgets don’t cover the needs, and that will continue.
Mallott commented on that, “We’re here to serve our clients and we do it because we’re passionate about our clients. … We have to make sure the clients are cared for. That’s the bottom line.”
